Dengue fever in a patient with

severe
haemophilia
Bangun said santoso/ 03012047
 Dengue fever (DF) is a vector borne viral
disease caused by the dengue virus, which
belongs to the family filoviridae and genus
flavivirus

Haemophilia A is the most common inherited

bleedingdisorder, caused by defects in the gene
that encodes coagulation factor VIII. It is an
X-linked recessive disorder which occurs in
approximately 1:5000 males
 CASE
A 16-year-old Sinhalese male with severe haemophilia A (factor
level < 1%), was admitted to a teaching hospital in Sri Lanka on
Day 1 of an acute febrile illness. He had been diagnosed with
haemophilia in early childhood, but was not on prophylactic
factor VIII therapy.
Four days before admission, he had undergone a dental
extraction, with 30% factor correction with intravenous factor VIII
prior to the procedure.
One day before admission he had developed bleeding from the
extraction site, which had been treated with 750 IU of factor VIII
to achieve a 30% factor correction.
On the day of admission he had developed fever with chills and
rigors, associated with arthralgia, myalgia, nausea, vomiting and
severe frontal headache.
 CASE
DAY 1
On admission, he was febrile and flushed, with a heart rate of
120 beats per minute and a blood pressure of 110/70 millimetres
of mercury. The respiratory rate was 20 per minute, with clear
lungs on auscultation. The abdomen was soft, with mild epigastric
tenderness. Neurological examination including the fundus
examination was unremarkable. There was no evidence of
bleeding on clinical evaluation at the time of admission.
 CASE
DAY 1
Laboratory finding:
Hb 11,3 g/dl
Leukocyte 4400 /mm3
Platelet count 241,000 /mm3
Haematocrit 34,5 %
Neutrophils 47 %
Lympocytes 41 %
The erthyrocyte sedimentation rate, urine full report, serum
creatinine, hepatic tranasaminases, prothrombrin time and Chest
X-ray were all within normal limits and remained normal during
the entire hospital stay.
A clinical diagnosis of a possible undifferentiated viral fever or
dengue fever (DF) was made based on the history, examination
and investigations.
 CASE
DAY 2
On day 2 of the illness he complained of severe
throbbing headache associated with vomiting.
Neurological examination, including fundoscopy,
was normal. An urgent non-contrast
computerized tomography (CT) scan of the brain
excluded the presence of any intracranial
bleeding.
 CASE
DAY 3
On day 3 of the fever he developed recurrence of
bleeding from the tooth extraction site, together with
vomiting of dark red blood.
Platelet count 124,000/mm3
Haematocrit 32%
Intravenous factor VIII was given to achieve a 100% factor
correction over twenty four hours
Omeprazole was administered intravenously for
management of possible co-existing gastric erosions or
peptic ulcers.
 CASE
DAY 4
Factor correction was discontinued after 24 hours (on
day 4) as bleeding had settled and activated partial
thromboplastin time (APTT) was in the normal range.
DAY 5
Fever resolved
DAY 6
His platelet count dropped progressively from day1 to a
nadir of 50,000/mm3.
During the course of the illness he did not develop any
clinical evidence of fluid leakage or become
haemodynamically unstable
 CASE
DAY 7
platelet count of 69,000/mm3.
 Subsequently DF was confirmed by sero-
conversion with the dengue IgM antibody test
(MAC-ELISA, M Antibody capture- Enzyme
Linked Immunosorbent Assay) on the tenth day.
He was managed as dengue, according to the
national dengue management guidelines.
hourly monitoring of fluid balance, pulse rate
and blood pressure
The haematocrit and platelet counts were
checked thrice per day
The patient was frequently clinically evaluated to
detect the presence of any bleeding.
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Department of Census and statistics - Sri Lanka. Statistical
Pocket Book
[http://www.statistics.gov.lk/Pocket%20Book/chap02.pdf].
Accessed 23 Jan 2015.
World Health Organization Regional office for Southeast Asia.
Reported cases of dengue and deaths from SEA countries 2000
2011 [http://www.searo.
who.int/entity/vector_borne_tropical_diseases/ReportedCasesD
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